These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …)
• 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
• 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

• 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
• 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
• 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are mutually exclusive because the newborn care codes (99460-99463) are for “normal” newborns (i.e., newborns without medical problems); whereas the subsequent hospital care codes (99231-99233) are for problem-oriented services, Moore says.

Since both sets of services are designated as “per day,”coders must choose between them for a given patient on a given date. “Consistent with the mutually exclusive nature of these services, CCI does not permit a modifier to override the edits,” Moore continues.

Bottom line: Never report 99460-99262 and 99231-99233 for the same patient on the same date of service.

@ Family Practice Coding Alert. Editor: Chris Boucher, CPC

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Test your 2010 consultation coding understanding with these questions and answers.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by taking this three-question quiz and then checking your answers against the experts’.

Question 1: When a visit with a Medicare inpatient that would normally have been coded as a consultation does not meet the requirements of an initial inpatient hospital care code, what should you report?

Question 2: What modifier do admitting physicians need to use in 2010 when they report an initial hospital care code (99221-99223)?

Question 3: When Medicare is the patient’s secondary insurance and his primary insurance accepts the consultation codes, should you use a consultation code for the Medicare Secondary Payer (MSP) as well?

Answer 1: Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221- 99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the “Not Otherwise Classified” (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

Answer 2: Stick With 2 Letters for Admitting Physician

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you’re billing for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code.

This will denote the admitting physician who is overseeing the patient’s care, “as distinct from other physicians who may be furnishing specialty care,” according to CMS Transmittal 1875 (www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf).

Example: A trauma surgeon admits from the emergency room a patient who was involved in a motor vehicle accident and calls in an orthopedic surgeon to perform a consult for multiple fractures in the patient’s leg. The trauma surgeon would report 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) with modifier AI appended. The orthopedic surgeon then bills 99221-99223 with no modifier for his initial examination of the patient whether the visit represents a consultation or a new visit.

Remember: The new modifier is made up of two letters. “Some people are interpreting the new modifier as a ‘one,’” Cobuzzi says. “But it’s two letters, A and I,” she reminds coders. Think: A-eye.

Answer 3: Skip 99241-99255 for Medicare, Even as Secondary

Don’t even think about billing a consult to Medicare — even if the claim is to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultations codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation, and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare. The MSP “will not pay for consults,” says Samantha Daily, a medical biller for a practice in Portland, Ore.

Official word: MLN Matters article MM6740 indicates the following: “In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation …]. If the primary payer for the service continues to recognize consultation codes” you should bill for secondary payment from Medicare in one of the following two ways:

Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or Bill the primary payer using a consult code, and then report the amount paid by the primary payer, and change the code to the non-consult E/M code (that is equal to the consultation code/service documented and paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the physician may not know whether a hospitalized patient is on Medicare or another insurance when he documents his consultation and determines code assignment for the billing department.

You will need to be able to glean an appropriate E/M code from your physician’s consult documentation if the patient ends up also having Medicare as secondary insurance.

@ Medical Office Billing & Collections Alert

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Test your 2010 consultation coding understanding with these questions.

Consultation coding has every practice on edge this year. Ensure that you’ve got a handle on this complicated coding and billing situation by trying your hand at this question.

Question: When a visit with a Medicare inpatient that would normally have been coded as a consultation does not meet the requirements of an initial inpatient hospital care code, what should you report?

Click ‘read more’ for answer …

Answer: Check With Your MAC for Guidance

When your physician sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code (99221- 99223). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor’s (MAC) or carrier’s policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your physician’s documentation does not reach this level, there is a question as to what CPT codes you should use.

Option 1: Some MACs/carriers have stated that you should use the subsequent hospital care codes (99231-99233). “Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. She adds that instructions about whether or not to use 99499 seem to be MAC-by-MAC specific right now.

Option 2: Other MACs, however, have instructed practices to use the “Not Otherwise Classified” (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. For example, WPS Medicare states on its Web site: “Many providers have questioned the use of a subsequent care code when the provider does not meet the requirements of an initial care code. Wisconsin Physicians Service (WPS) Medicare advises the use of Not Otherwise Classified (NOC) code 99499 as stated in the Internet-Only Manual (IOM).”

“Check with your contractor,” Buechner advises. “Code 99499 is the correct coding choice by CPT rules.” Some payers, such as Highmark, don’t seem to like that coding, however, so you need to know what code(s) your payers want you to use.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code “that most appropriately describes the level of services provided,” notes MLN Matters article MM6740.

AUDIO: What surgical coders need to know about the 2010 consult revisions.

Stay tuned to Coding News for more consult coding quiz questions!

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Sort your normal, sick and intensive care options.

Choosing the appropriate codes for initial newborn services can be difficult due to the large number of available codes and gray areas between the spectrum of illnesses. If you find yourself getting tripped up by the multiple categories, read on for expert tips and real-world examples that will point you in the right direction every time.

Normal Care Means No Problems

A “normal” newborn has no medical conditions or need for special care. Report the history and examination with 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant).

Donelle Holle, RN, a consultant with Pedscoding.com in Indiana says this initial care includes five things:

• Maternal and/or fetal and newborn history

• Newborn physical examination

• Ordering of diagnostic tests and treatments

• Meetings with the family

• Documentation in the medical record.

Diagnosis tip: When billing with 99460, include diagnosis V30.x x (Single liveborn). “Because 99460 states ‘normal newborn,’ you cannot have any other diagnosis for that CPT code,” Holle explains.

Add-ons: Procedures such as circumcision (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block or 54160, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) are not included with the normal newborn codes (99460-99463). Be sure to code the circumcision in addition to the newborn care. To indicate 99460-99463 is significantly identifiable from the minor E/M included in surgical codes, append 99460-99463 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Sick Newborn Needs Inpatient Codes

When the pediatrician provides E/M services for newborns who are other than normal, CPT directs you to report the codes for hospital inpatient (99221-99233) or neonatal intensive (99477-99480)  or critical care (99468-99469) services.

A baby considered a “sick” newborn might have a fever, high hemoglobin count, or MILD RESP DISTRESS. For a sick newborn, you’ll select from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) for the first day, based on the level of history, examination, and medical decision making.

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The physician orders a culture and initiates IV antibiotics for the newborn. Report services for the initial day of the sick newborn’s care with the appropriate choice from 99221-99223.

Intensive Care Require Extra Monitoring

Sometimes infants and neonates are not critically ill but need intensive cardiac or respiratory monitoring, continuous and/or frequent vital signs monitoring, heat maintenance, nutritional adjustments, or laboratory and oxygen monitoring. These babies also require constant observation by the health care team under direct physician supervision.

“These infants are not critically ill but do require further monitoring or services that MAY require them to be in the neonatal intensive care unit (NICU),” Holle says.

Remember the level of care delivered — not the site of service — determines the code you choose, says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Intensive care codes could apply to a baby in the newborn nursery or NICU.

Example: An infant is born at 37 weeks gestation with mild tachypnea and requires 30 percent O2 by nasal cannula. The pediatrician acquires cultures and initiates IV antibiotics. Close monitoring is maintained; no additional intervention is indicated.

For the first day of this baby’s care, report 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services). Additional days should be coded according to the infant’s status.

• “If the neonate continues to require intensive monitoring, frequent interventions, observation, or other intensive care services, use the low birth weight or recovering infant codes,” Holle says. Choose from 99478-99480 (Subsequent intensive care, per day, for the evaluation and management of the recovering infant …), based on the infant’s weight.

• If the child is still ill but no longer requires intensive or critical care services, Holle says to select from 99321-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …).

• “Sometimes a child moves from being intensively ill to being ill, to being well,” Tuck explains.  Once the child is well, turn to 99462.

What should you report if neonates meet critical care status? Subscribe to the Pediatric Coding Alert or go to www.supercoder.com for the answer.

Want to know more? Sign up now for Dr. Richard Lander’s Pediatric Coding: Simple as ABC audioconference before it’s sold out!

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